p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e9
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Original Research
Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study M.P. Pattussi a,*, M.T. Anselmo Olinto a,b, H.B. Rower a, F. Souza de Bairros a, I. Kawachi c ~ o em Sau´de Coletiva, Universidade do Vale do Rio dos Sinos, Avenida Unisinos 950, Sa ~o Programa de P os graduac¸a Leopoldo, RS 93022-000, Brazil b ~o, Universidade Federal de Ci^encias da Sau´de, Rua Sarmento Leite 245, Porto Alegre, RS Departamento de Nutric¸a 90050-170, Brazil c Department of Social and Behavioural Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA a
article info
abstract
Article history:
Objective: The relationship between social capital and mortality is not clear-cut. There have
Received 9 March 2015
been few longitudinal studies investigating this association so far. The objective was to
Received in revised form
assess the effect of different dimensions of social capital on mortality among adults of a
12 December 2015
Brazilian city.
Accepted 16 December 2015
Study design: This is a prospective multilevel study. Baseline data were obtained from a
Available online xxx
population-based random sample of 846 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks).
Keywords:
Methods: Participants were interviewed in 2006e7 and their vital status investigated in 2013.
Mortality
Social capital was assessed by five scales (social cohesion, informal social control, neigh-
Social capital
bours' support, social action and political efficacy). The outcome was all-cause mortality.
Social cohesion
Data analysis used multilevel logistic regression models.
Multilevel
Results: At the individual level social cohesion was positively related to mortality in the
Cohort
unadjusted model but this association lost significance after adjustment for other variables
Adults
in multivariable models. At the neighbourhood level, high mortality rates were associated with low social action independently of demographic, socio-economic, behavioural and health-related variables. Conclusion: We found more evidence for a contextual than individual level effect of social capital on mortality. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
s-graduac¸a ~ o em Sau´de Coletiva, Universidade do Vale do Rio dos Sinos (UNISINOS), Av. Unisinos * Corresponding author. Programa de Po ~ o Leopoldo, Rio Grande do Sul, Brazil. Tel.: þ55 (51) 35908752; fax: þ55 (51) 35908122. 950, CEP 93022-000, Sa E-mail addresses: [email protected], [email protected] (M.P. Pattussi), [email protected] (M.T. Anselmo Olinto), [email protected] (H.B. Rower), [email protected] (F. Souza de Bairros), [email protected] (I. Kawachi). http://dx.doi.org/10.1016/j.puhe.2015.12.007 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
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p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e9
Introduction Social capital has been defined as the resources derived from membership in social networks. At the individual level, these resources include access to information, the exchange of tangible resources, as well as social reinforcement. At the group level, social capital consists of group solidarity and cohesion, which in turn enables the collective to undertake coordinated action and to enforce social norms.1 The potential relevance of social capital for population health has been explored in a fast growing body of research. A general search in PubMed using ‘social capital and health’ reveals that over 2500 articles have been generated during the past ten years (2004e2014) on the subject of social capital and population health. Several reviews have also been published.2e18 Despite variations across individual studies in the manner in which social capital has been operationalized and measured, the preponderance of evidence suggests a positive correlation between social capital and health (although the reviews at the same time point to health-damaging aspects of ‘too strong’ social capital in some contexts).19 An important distinction that has emerged from the literature is the difference between the health consequences of individual access to social capital versus community-level stocks of social capital. At the individual level, a recent meta-analysis of cohort studies15 investigating the effect of cognitive (trust and social support) and structural (social participation and social networks) social capital on mortality, reported a strong association between higher social participation and lower mortality rates. However, the association between perceptions of trust and health was less robust. At the area level, a review of prospective multilevel studies13 showed mixed results and limited evidence about the effect of social capital on all-cause mortality. There have been few longitudinal studies investigating this association so far. High levels of social capital did not always generate positive health advantages.20 In addition, the majority of studies reviewed so far have been conducted in developed countries and literature in Latin America remains sparse.21,22 The objective of this study was therefore to examine prospectively the associations of different dimensions of social capital at the individual and neighbourhood level on mortality among adults of a Brazilian city.
Methods Setting ~ o LeoThe research was carried out in the municipality of Sa poldo, located in the State of Rio Grande do Sul (RS) in the south of Brazil. According to the 2010 Demographic Census23 it is a city with 214,087 inhabitants. The major economic activities of the municipality are based on industry and services. The per capita Gross Domestic Product was around eleven thousand USA dollars in 2010. It is a relatively rich city compared to other Brazilian regions but income is unequally distributed. According to the Brazilian Institute of Geography and Statistics (IBGE) one-fifth of the richest households
account for 58% of the Gross Domestic Product. The city has two hospitals, one private and one public, as well as 39 primary health care units.
Study design Our analysis was based on a prospective multilevel study. Baseline data were obtained from a population-based random sample of 1100 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks). Census blocks are the smallest unit of information available from the Brazilian census. They include an average of 300 households and 1000 people, and are numbered consecutively from the central area of the city to the suburbs, following a spiral pattern. Face-toface interviews were conducted at each participant's home using a structured, pre-coded, and pre-tested questionnaire from January 2006 to July 2007. The questionnaire included data on self-reported outcomes as well as demographic, socioeconomic, behavioural, psychosocial variables. Neighbourhood variables were obtained from the 2000 Census and also by aggregating participants' responses. A detailed description of the baseline survey is available elsewhere.24,25 In early 2013 we attempted to locate all the participants using the addresses available from the baseline wave of the study. The main objective was to assess the influence of social capital on the respondents' health status after seven years, especially their vital status. Only those who participated in the baseline were eligible. Those who changed their address (n ¼ 254) were excluded because we considered them to be no longer ‘exposed’ to the levels of social capital in their neighbourhood of origin.
Outcome The primary outcome was all-cause mortality Participants' deaths were ascertained via the official death registration records of the Rio Grande do Sul state. The vital status of those not present at home was confirmed with neighbours and at the time of interview.
Exposures The exposures of interest were five social capital scales adapted from the literature. They were constructed to encompass specific dimensions of social capital, namely bonding, bridging and linking social capital.26 Bonding social capital refers to horizontal tight knit ties between individuals or groups sharing similar demographic characteristics. Examples of this form of capital include the bonds between family members and close friends. By contrast bridging social capital refers to the linkages between groups and individuals that cut across social class, ethnicity, and other characteristics. Bridging capital is vital for enabling individuals and communities to access resources or opportunities outside their personal networks. Linking social capital refers to alliances with people across explicit hierarchical levels of power, especially individuals or groups in positions with command over resources needed for social and economic development.26 The following scales representing these constructs were used: social cohesion (five items),27 informal social
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
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control (five items),27 neighbours' support (four items),28 social action (five items)29,30 and political efficacy (four items)30 (see31 for detailed information) (Supplemental Table 1). Exploratory and confirmatory factor analysis were conducted to assess the psychometric properties of these scales. The model fit indicated acceptable validity and reliability (Alpha >0.6 in all scales; CFI ¼ 0.99; TLI ¼ 0.98; RMSEA ¼ 0.05). We examined the associations between these social capital variables and mortality risk at both the individual and the neighbourhood level. At the individual level items were summed up and the variable categorised based on the tertiles of distribution. Because they were negative statements, political efficacy items were reverse coded. At the neighbourhood level, the mean score for each participant was aggregated up to the neighbourhood level. Using the neighbourhood distribution, neighbourhoods were then dichotomized to compare low (P33%) Low (P33%) Individual Social Cohesion High (P66%) Moderate (P33%) Low (P33%) Sex Female Male Age in years (grand mean) Marital Status Married/Union Single Divorced/Widow Schooling High (12 years) Middle (5e11) Low (4) Smoking Non-smoker Former-smoker Smoker Medical appointments (last month) 0 1 2 Hospitalization (last year) No Yes Morbidities (last month) 0 1e2 3
Model 2 OR (95%CI)
Model 3 OR (95%CI)
Model 4 OR (95%CI)
1 2.72 (1.50e4.93)
1 2.66 (1.38e5.1)
1 2.64 (1.35e5.17)
1 2.48 (1.19e5.15)
1 0.42 (0.18e0.99) 0.34 (0.16e0.72)
1 0.51 (0.21e1.19) 0.56 (0.25e1.22)
1 0.61 (0.25e1.47) 0.60 (0.27e1.33)
1 0.53 (0.21e1.34) 0.52 (0.22e1.23)
1 1.96 (1.01e3.81) 1.11 (1.08e1.14)
1 1.63 (0.83e3.19) 1.10 (1.07e1.13)
1.11 (1.07e1.14)
1 1.90 (0.84e4.33) 1.10 (1.06e1.13)
1 0.43 (0.13e1.38) 2.73 (1.38e5.41)
1 1.31 (0.38e4.54) 1.63 (0.73e3.62)
1 2.47 (0.64e9.57) 4.05 (0.95e17.24)
1 0.98 (0.25e3.75) 0.79 (0.18e3.59)
1 3.15 (153e6.48) 1.31 (0.53e3.21)
1 2.33 (1.10e4.91) 1.94 (0.77e4.88)
1 1.81 (0.81e4.16) 1.71 (0.79e3.70) 1 3.27(1.56e6.88) 1 3.87 (1.64e9.11) 9.70 (3.6e26.15)
1 2.51 (1.07e5.87) 2.67 (0.99e7.20) 1 2.22 (0.92e5.37) 1.23 (0.52e2.94)
1 3.77 (1.69e8.41)
1 4.06 (1.68e9.83) 1 1.67 (0.66e4.21) 2.23 (0.73e6.85)
Bold values are statistically significant (P < 0.05); Model 1 e unadjusted effect of all variables. Model 2 e social capital variables adjusted for age and sex. Model 3 e social capital variables adjusted for age, smoking and hospitalization (through a backward elimination procedure). Model 4 e social capital variables adjusted for all potential confounders (associations with P < 0.1).
on the willingness to intervene for the common good, a condition that entails mutual trust and solidarity among local residents. Bonding social capital, has been related to better access to a regular doctor, receipt of preventive care and utilization based on need.4 However, when beliefs and or experiences are not conducive to health, as in our study, bridging and linking social capital may be more important.4 To some extent, our results are similar to those studies reporting an association between structural pluralism40 and civic communities41 with low mortality. It has been argued that, in more active neighbourhoods, people have greater capacity to solve their local problems and/or that there may be institutional infrastructures in place that facilitate their engagement and actions.40,41 The development or maintenance of local care facilities, the retention of health personnel, or even dissemination of awareness or access to health information may then be facilitated in high social action areas. This may have to do with what42 have called ‘community accountability’: i.e. ‘the structures and processes communities use to make health system change consistent with local standards of behaviour, shared values, or community goals.’ In addition, it has been shown that neighbourhood effects
often refer to improvement in their access to health resources, sports facilities, types of food shops, walkability, air and noise pollution.43 Social capital at community or neighbourhood level may be about collective action to improve these features of the local environment.44 Future research would benefit from studies aiming to clarify the mechanisms of action and unravel the potential mediators and moderators in the relationship between social capital and mortality. Our unexpected finding of lower individual perceptions of social cohesion being associated with lower mortality may be because the items that comprised the scale were not appropriate for capturing individual effects. They refer mainly to features of neighbourhoods and neighbours rather than to individual attributes. Psychosocial variables at the individual level would include aspects such as social network and support. It may also be speculated that the cohesive societies may be more conservative and with rigid social structures that may overburden people with obligations while discouraging health promoting behaviour.45 Or it may reflect a real downside of social capital. Some forms of social capital may be more valuable to facilitate some actions than others.43 For example, Subramanian and colleagues20 showed that the health-
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e9
promoting effect of community social trust was significantly greater for high-trust individuals, but it was in the opposite direction for low-trust individuals. On the other hand, we found that lower individual perceptions of social cohesion on mortality was no longer significant when age was added as a covariate. The unadjusted findings are therefore likely to be confounded by age. We found more evidence for a neighbourhood rather than individual effect of social capital on health. There is some debate about whether social capital is an individual attribute or a characteristic of communities or societies. Poortinga46 has suggested that the beneficial properties of social capital to self-rated health are mainly attributable to the social networks of individuals. However, in a subsequent paper the author also showed effects of variables defined at a group level independently of individual characteristics.47 The contributions of social capital lies in the collective dimension because it directs our attention to group-level mechanisms that may influence health-related behaviours and health outcomes.8 Both levels must be considered when investigating the potential impact of social capital on health. This paper has several limitations. First, we used administrative boundaries to define the contours of neighbourhood social capital. It has been argued that the use of administrative boundaries may not be the most appropriate spatial scale to analyse the associations between social capital and health. The modifiable areal unit problem may result in misclassification or inaccurate estimations of effects of neighbourhood characteristics on health.48,49 Studies investigating the effect of a range of different areal units of analysis are necessary. In addition, another limitation is that the aggregate measures of social capital used are not truly ecological, therefore it is uncertain that they are measuring the level in question.50 Studies focussing on direct observation of social capital on neighbourhoods are necessary. In addition, the presence of attrition bias due to losses to follow-up cannot be ruled out. It may be that healthy people move away from low social capital neighbourhoods. However, this does not seem to be the case since there was no association between participants' change of address and levels of social capital variables. Lower mortality rates have been associated with residential mobility in England51 and Sweden.52 The presence of type II error cannot be excluded either. Because the small number of neighbourhoods and of deaths, the sample may not have had sufficient power to detect statistically significant differences. On the other hand, longitudinal studies on this subject, such as ours, are relatively scarce and particularly derived from developed countries. Prospective studies are particularly adequate because temporal sequence between exposure and outcome can be more clearly elucidated. In addition, because the outcomes of interest have not yet occurred at the time the study is begun, bias in the selection of subjects is minimized.56 Finally, residual bias cannot be ruled out because potentially relevant factors that might have confounded the association such as depression, loneliness, and living alone were not collected at baseline. In summary, we found more evidence for a contextual level effect of social capital on mortality. However, it has been shown that neighbourhood effects are likely to vary over time, between societies, depending on the indicators used, variables
7
adjusted for or the areal unit adopted.43,53 The role of social capital on health has to be considered in the context of the social and political environment. These contexts are essential for shaping policies and policy institutions.54 The context dependence of social capital is justified because not all actors in a group, community or polity, have equal access to the same resources. Resources and access are not distributed evenly, they are not equally available to all individuals or collective actors operating within specific geographic or organizational boundaries. The value of social capital may depend upon how specific networks are embedded within the broader system socio-economic and political context.55
Author statements Ethical approval The research protocol was approved by the UNISINOS Research Ethics Committee (CEP 04/034 and CEP11/054). Informed consent was sought and obtained from all subjects.
Funding Financial support was provided by the Coordination for the Improvement of Higher Level Personnel (CAPES), grant 10599134; National Council for Scientific and Technological Development, grants 47850320040 and 48141020090; and; Rio Grande do Sul State Research Foundation (FAPERGS) grants 0415621 and 1121774. MTAO and MPP received research productivity grants from the CNPq, number 30479320108 and 30342420117 respectively.
Competing interests There is no conflict of interest in this paper.
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Appendix A Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.puhe.2015.12.007.
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study M.P. Pattussi a,*, M.T. Anselmo Olinto a,b, H.B. Rower a, F. Souza de Bairros a, I. Kawachi c ~ o em Sau´de Coletiva, Universidade do Vale do Rio dos Sinos, Avenida Unisinos 950, Sa ~o Programa de P os graduac¸a Leopoldo, RS 93022-000, Brazil b ~o, Universidade Federal de Ci^encias da Sau´de, Rua Sarmento Leite 245, Porto Alegre, RS Departamento de Nutric¸a 90050-170, Brazil c Department of Social and Behavioural Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA a
article info
abstract
Article history:
Objective: The relationship between social capital and mortality is not clear-cut. There have
Received 9 March 2015
been few longitudinal studies investigating this association so far. The objective was to
Received in revised form
assess the effect of different dimensions of social capital on mortality among adults of a
12 December 2015
Brazilian city.
Accepted 16 December 2015
Study design: This is a prospective multilevel study. Baseline data were obtained from a
Available online xxx
population-based random sample of 846 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks).
Keywords:
Methods: Participants were interviewed in 2006e7 and their vital status investigated in 2013.
Mortality
Social capital was assessed by five scales (social cohesion, informal social control, neigh-
Social capital
bours' support, social action and political efficacy). The outcome was all-cause mortality.
Social cohesion
Data analysis used multilevel logistic regression models.
Multilevel
Results: At the individual level social cohesion was positively related to mortality in the
Cohort
unadjusted model but this association lost significance after adjustment for other variables
Adults
in multivariable models. At the neighbourhood level, high mortality rates were associated with low social action independently of demographic, socio-economic, behavioural and health-related variables. Conclusion: We found more evidence for a contextual than individual level effect of social capital on mortality. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
s-graduac¸a ~ o em Sau´de Coletiva, Universidade do Vale do Rio dos Sinos (UNISINOS), Av. Unisinos * Corresponding author. Programa de Po ~ o Leopoldo, Rio Grande do Sul, Brazil. Tel.: þ55 (51) 35908752; fax: þ55 (51) 35908122. 950, CEP 93022-000, Sa E-mail addresses: [email protected], [email protected] (M.P. Pattussi), [email protected] (M.T. Anselmo Olinto), [email protected] (H.B. Rower), [email protected] (F. Souza de Bairros), [email protected] (I. Kawachi). http://dx.doi.org/10.1016/j.puhe.2015.12.007 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
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Introduction Social capital has been defined as the resources derived from membership in social networks. At the individual level, these resources include access to information, the exchange of tangible resources, as well as social reinforcement. At the group level, social capital consists of group solidarity and cohesion, which in turn enables the collective to undertake coordinated action and to enforce social norms.1 The potential relevance of social capital for population health has been explored in a fast growing body of research. A general search in PubMed using ‘social capital and health’ reveals that over 2500 articles have been generated during the past ten years (2004e2014) on the subject of social capital and population health. Several reviews have also been published.2e18 Despite variations across individual studies in the manner in which social capital has been operationalized and measured, the preponderance of evidence suggests a positive correlation between social capital and health (although the reviews at the same time point to health-damaging aspects of ‘too strong’ social capital in some contexts).19 An important distinction that has emerged from the literature is the difference between the health consequences of individual access to social capital versus community-level stocks of social capital. At the individual level, a recent meta-analysis of cohort studies15 investigating the effect of cognitive (trust and social support) and structural (social participation and social networks) social capital on mortality, reported a strong association between higher social participation and lower mortality rates. However, the association between perceptions of trust and health was less robust. At the area level, a review of prospective multilevel studies13 showed mixed results and limited evidence about the effect of social capital on all-cause mortality. There have been few longitudinal studies investigating this association so far. High levels of social capital did not always generate positive health advantages.20 In addition, the majority of studies reviewed so far have been conducted in developed countries and literature in Latin America remains sparse.21,22 The objective of this study was therefore to examine prospectively the associations of different dimensions of social capital at the individual and neighbourhood level on mortality among adults of a Brazilian city.
Methods Setting ~ o LeoThe research was carried out in the municipality of Sa poldo, located in the State of Rio Grande do Sul (RS) in the south of Brazil. According to the 2010 Demographic Census23 it is a city with 214,087 inhabitants. The major economic activities of the municipality are based on industry and services. The per capita Gross Domestic Product was around eleven thousand USA dollars in 2010. It is a relatively rich city compared to other Brazilian regions but income is unequally distributed. According to the Brazilian Institute of Geography and Statistics (IBGE) one-fifth of the richest households
account for 58% of the Gross Domestic Product. The city has two hospitals, one private and one public, as well as 39 primary health care units.
Study design Our analysis was based on a prospective multilevel study. Baseline data were obtained from a population-based random sample of 1100 adults (aged 18 years or more) residing in 38 neighbourhoods (census blocks). Census blocks are the smallest unit of information available from the Brazilian census. They include an average of 300 households and 1000 people, and are numbered consecutively from the central area of the city to the suburbs, following a spiral pattern. Face-toface interviews were conducted at each participant's home using a structured, pre-coded, and pre-tested questionnaire from January 2006 to July 2007. The questionnaire included data on self-reported outcomes as well as demographic, socioeconomic, behavioural, psychosocial variables. Neighbourhood variables were obtained from the 2000 Census and also by aggregating participants' responses. A detailed description of the baseline survey is available elsewhere.24,25 In early 2013 we attempted to locate all the participants using the addresses available from the baseline wave of the study. The main objective was to assess the influence of social capital on the respondents' health status after seven years, especially their vital status. Only those who participated in the baseline were eligible. Those who changed their address (n ¼ 254) were excluded because we considered them to be no longer ‘exposed’ to the levels of social capital in their neighbourhood of origin.
Outcome The primary outcome was all-cause mortality Participants' deaths were ascertained via the official death registration records of the Rio Grande do Sul state. The vital status of those not present at home was confirmed with neighbours and at the time of interview.
Exposures The exposures of interest were five social capital scales adapted from the literature. They were constructed to encompass specific dimensions of social capital, namely bonding, bridging and linking social capital.26 Bonding social capital refers to horizontal tight knit ties between individuals or groups sharing similar demographic characteristics. Examples of this form of capital include the bonds between family members and close friends. By contrast bridging social capital refers to the linkages between groups and individuals that cut across social class, ethnicity, and other characteristics. Bridging capital is vital for enabling individuals and communities to access resources or opportunities outside their personal networks. Linking social capital refers to alliances with people across explicit hierarchical levels of power, especially individuals or groups in positions with command over resources needed for social and economic development.26 The following scales representing these constructs were used: social cohesion (five items),27 informal social
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
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control (five items),27 neighbours' support (four items),28 social action (five items)29,30 and political efficacy (four items)30 (see31 for detailed information) (Supplemental Table 1). Exploratory and confirmatory factor analysis were conducted to assess the psychometric properties of these scales. The model fit indicated acceptable validity and reliability (Alpha >0.6 in all scales; CFI ¼ 0.99; TLI ¼ 0.98; RMSEA ¼ 0.05). We examined the associations between these social capital variables and mortality risk at both the individual and the neighbourhood level. At the individual level items were summed up and the variable categorised based on the tertiles of distribution. Because they were negative statements, political efficacy items were reverse coded. At the neighbourhood level, the mean score for each participant was aggregated up to the neighbourhood level. Using the neighbourhood distribution, neighbourhoods were then dichotomized to compare low (P33%) Low (P33%) Individual Social Cohesion High (P66%) Moderate (P33%) Low (P33%) Sex Female Male Age in years (grand mean) Marital Status Married/Union Single Divorced/Widow Schooling High (12 years) Middle (5e11) Low (4) Smoking Non-smoker Former-smoker Smoker Medical appointments (last month) 0 1 2 Hospitalization (last year) No Yes Morbidities (last month) 0 1e2 3
Model 2 OR (95%CI)
Model 3 OR (95%CI)
Model 4 OR (95%CI)
1 2.72 (1.50e4.93)
1 2.66 (1.38e5.1)
1 2.64 (1.35e5.17)
1 2.48 (1.19e5.15)
1 0.42 (0.18e0.99) 0.34 (0.16e0.72)
1 0.51 (0.21e1.19) 0.56 (0.25e1.22)
1 0.61 (0.25e1.47) 0.60 (0.27e1.33)
1 0.53 (0.21e1.34) 0.52 (0.22e1.23)
1 1.96 (1.01e3.81) 1.11 (1.08e1.14)
1 1.63 (0.83e3.19) 1.10 (1.07e1.13)
1.11 (1.07e1.14)
1 1.90 (0.84e4.33) 1.10 (1.06e1.13)
1 0.43 (0.13e1.38) 2.73 (1.38e5.41)
1 1.31 (0.38e4.54) 1.63 (0.73e3.62)
1 2.47 (0.64e9.57) 4.05 (0.95e17.24)
1 0.98 (0.25e3.75) 0.79 (0.18e3.59)
1 3.15 (153e6.48) 1.31 (0.53e3.21)
1 2.33 (1.10e4.91) 1.94 (0.77e4.88)
1 1.81 (0.81e4.16) 1.71 (0.79e3.70) 1 3.27(1.56e6.88) 1 3.87 (1.64e9.11) 9.70 (3.6e26.15)
1 2.51 (1.07e5.87) 2.67 (0.99e7.20) 1 2.22 (0.92e5.37) 1.23 (0.52e2.94)
1 3.77 (1.69e8.41)
1 4.06 (1.68e9.83) 1 1.67 (0.66e4.21) 2.23 (0.73e6.85)
Bold values are statistically significant (P < 0.05); Model 1 e unadjusted effect of all variables. Model 2 e social capital variables adjusted for age and sex. Model 3 e social capital variables adjusted for age, smoking and hospitalization (through a backward elimination procedure). Model 4 e social capital variables adjusted for all potential confounders (associations with P < 0.1).
on the willingness to intervene for the common good, a condition that entails mutual trust and solidarity among local residents. Bonding social capital, has been related to better access to a regular doctor, receipt of preventive care and utilization based on need.4 However, when beliefs and or experiences are not conducive to health, as in our study, bridging and linking social capital may be more important.4 To some extent, our results are similar to those studies reporting an association between structural pluralism40 and civic communities41 with low mortality. It has been argued that, in more active neighbourhoods, people have greater capacity to solve their local problems and/or that there may be institutional infrastructures in place that facilitate their engagement and actions.40,41 The development or maintenance of local care facilities, the retention of health personnel, or even dissemination of awareness or access to health information may then be facilitated in high social action areas. This may have to do with what42 have called ‘community accountability’: i.e. ‘the structures and processes communities use to make health system change consistent with local standards of behaviour, shared values, or community goals.’ In addition, it has been shown that neighbourhood effects
often refer to improvement in their access to health resources, sports facilities, types of food shops, walkability, air and noise pollution.43 Social capital at community or neighbourhood level may be about collective action to improve these features of the local environment.44 Future research would benefit from studies aiming to clarify the mechanisms of action and unravel the potential mediators and moderators in the relationship between social capital and mortality. Our unexpected finding of lower individual perceptions of social cohesion being associated with lower mortality may be because the items that comprised the scale were not appropriate for capturing individual effects. They refer mainly to features of neighbourhoods and neighbours rather than to individual attributes. Psychosocial variables at the individual level would include aspects such as social network and support. It may also be speculated that the cohesive societies may be more conservative and with rigid social structures that may overburden people with obligations while discouraging health promoting behaviour.45 Or it may reflect a real downside of social capital. Some forms of social capital may be more valuable to facilitate some actions than others.43 For example, Subramanian and colleagues20 showed that the health-
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e9
promoting effect of community social trust was significantly greater for high-trust individuals, but it was in the opposite direction for low-trust individuals. On the other hand, we found that lower individual perceptions of social cohesion on mortality was no longer significant when age was added as a covariate. The unadjusted findings are therefore likely to be confounded by age. We found more evidence for a neighbourhood rather than individual effect of social capital on health. There is some debate about whether social capital is an individual attribute or a characteristic of communities or societies. Poortinga46 has suggested that the beneficial properties of social capital to self-rated health are mainly attributable to the social networks of individuals. However, in a subsequent paper the author also showed effects of variables defined at a group level independently of individual characteristics.47 The contributions of social capital lies in the collective dimension because it directs our attention to group-level mechanisms that may influence health-related behaviours and health outcomes.8 Both levels must be considered when investigating the potential impact of social capital on health. This paper has several limitations. First, we used administrative boundaries to define the contours of neighbourhood social capital. It has been argued that the use of administrative boundaries may not be the most appropriate spatial scale to analyse the associations between social capital and health. The modifiable areal unit problem may result in misclassification or inaccurate estimations of effects of neighbourhood characteristics on health.48,49 Studies investigating the effect of a range of different areal units of analysis are necessary. In addition, another limitation is that the aggregate measures of social capital used are not truly ecological, therefore it is uncertain that they are measuring the level in question.50 Studies focussing on direct observation of social capital on neighbourhoods are necessary. In addition, the presence of attrition bias due to losses to follow-up cannot be ruled out. It may be that healthy people move away from low social capital neighbourhoods. However, this does not seem to be the case since there was no association between participants' change of address and levels of social capital variables. Lower mortality rates have been associated with residential mobility in England51 and Sweden.52 The presence of type II error cannot be excluded either. Because the small number of neighbourhoods and of deaths, the sample may not have had sufficient power to detect statistically significant differences. On the other hand, longitudinal studies on this subject, such as ours, are relatively scarce and particularly derived from developed countries. Prospective studies are particularly adequate because temporal sequence between exposure and outcome can be more clearly elucidated. In addition, because the outcomes of interest have not yet occurred at the time the study is begun, bias in the selection of subjects is minimized.56 Finally, residual bias cannot be ruled out because potentially relevant factors that might have confounded the association such as depression, loneliness, and living alone were not collected at baseline. In summary, we found more evidence for a contextual level effect of social capital on mortality. However, it has been shown that neighbourhood effects are likely to vary over time, between societies, depending on the indicators used, variables
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adjusted for or the areal unit adopted.43,53 The role of social capital on health has to be considered in the context of the social and political environment. These contexts are essential for shaping policies and policy institutions.54 The context dependence of social capital is justified because not all actors in a group, community or polity, have equal access to the same resources. Resources and access are not distributed evenly, they are not equally available to all individuals or collective actors operating within specific geographic or organizational boundaries. The value of social capital may depend upon how specific networks are embedded within the broader system socio-economic and political context.55
Author statements Ethical approval The research protocol was approved by the UNISINOS Research Ethics Committee (CEP 04/034 and CEP11/054). Informed consent was sought and obtained from all subjects.
Funding Financial support was provided by the Coordination for the Improvement of Higher Level Personnel (CAPES), grant 10599134; National Council for Scientific and Technological Development, grants 47850320040 and 48141020090; and; Rio Grande do Sul State Research Foundation (FAPERGS) grants 0415621 and 1121774. MTAO and MPP received research productivity grants from the CNPq, number 30479320108 and 30342420117 respectively.
Competing interests There is no conflict of interest in this paper.
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Appendix A Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.puhe.2015.12.007.
Please cite this article in press as: Pattussi MP, et al., Individual and neighbourhood social capital and all-cause mortality in Brazilian adults: a prospective multilevel study, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2015.12.007
